Page 6 of 6
These worksheets are solely for the purpose of completing the Pre-Application Worksheet
questions, on page 3, for the student and, on page 5, for the student’s parents.
Worksheet A
Report Annual Amounts
Student/Spouse Parent(s)
For Page 3 For Page 5
$
Earned income credit from IRS Form 1040—line 65a; 1040A—line 41a; 1040EZ—line 8a; or
TeleFile—line L
$
$ Additional child tax credit from IRS Form 1040—line 67 or 1040A—line 42 $
$
Welfare benefits, including Temporary Assistance for Needy Families (TANF). Don’t include
food stamps or subsidized housing.
$
$
Social Security benefits received, for all household members as reported in student’s household
size (or parents’ household size), that were not taxed (such as SSI). Report benefits paid to
parents in the parents’ column, and benefits paid directly to student in the student’s column.
$
Enter in Worksheet A question Enter in Worksheet A question
$ -- on Page 3 on Page 5-- $
Worksheet B
Report Annual Amounts
Student/Spouse Parent(s)
For Page 3 For Page 5
$
Payments to tax-deferred pension and savings plans (paid directly or withheld from earnings),
including, but not limited to, amounts reported on the W-2 Form in Boxes 12a through 12d,
codes D, E, F, G, H, and S.
$
$
IRA deductions and payments to self-employed SEP, SIMPLE, and Keogh and other qualified
plans from IRS Form 1040⎯total of lines 25 + 32 or 1040A⎯line 17
$
$ Child support you received for all children. Don’t include foster care or adoption payments. $
$
Tax exempt interest income from IRS Form 1040⎯line 8b or 1040A⎯line 8b
$
$
Foreign income exclusion from IRS Form 2555⎯line 43 or 2555EZ⎯line 18
$
$
Untaxed portions of IRA distributions from IRS Form 1040⎯lines (15a minus 15b) or
1040A⎯lines (11a minus 11b). Exclude rollovers. If negative, enter a zero here.
$
$
Untaxed portions of pensions from IRS Form 1040⎯lines (16a minus 16b) or 1040A⎯lines (12a
minus 12b). Exclude rollovers. If negative, enter a zero here.
$
$
Credit for federal tax on special fuels from IRS Form 4136⎯line 10⎯nonfarmers only
$
$
Housing, food, and other living allowances paid to members of the military, clergy, and others
(including cash payments and cash value of benefits)
$
$
Veterans’ noneducation benefits such as Disability, Death Pension, or Dependency & Indemnity
Compensation (DIC), and/or VA Educational Work-Study allowances
$
$
Any other untaxed income or benefits not reported elsewhere on Worksheets A and B, such as
workers’ compensation, untaxed portions of railroad retirement benefits, Black Lung Benefits,
disability, etc.
Don’t include student aid, Workforce Investment Act educational benefits, or benefits from
flexible spending arrangements, e.g., cafeteria plans
$
$ Money received, or paid on your behalf (e.g., bills), not reported elsewhere on this form
XXXXXXXXXXXXX
Enter in Worksheet B question Enter in Worksheet B question
$ -- on Page 3 on Page 5-- $
Worksheet C
Report Annual Amounts
Student/Spouse Parent(s)
For Page 3 For Page 5
$
Education credits (Hope and Lifetime Learning tax credits) from IRS Form 1040⎯line 49 or
1040A⎯line 31
$
$
Child support you paid because of divorce or separation or as a result of a legal requirement.
Don’t include support for children in your (or your parents’) household.
$
$
Taxable earnings from need-based employment programs, such as Federal Work-Study and need-
based employment portions of fellowships and assistantships.
$
$
Student grant and scholarship aid reported to the IRS in your (or your parents’) adjusted gross
income. Includes AmeriCorps benefits (awards, living allowances, and interest accrual
payments), as well as grant or scholarship portions of fellowships and assistantships.
$
Enter in Worksheet C question Enter in Worksheet C question
$ -- on Page 3 on Page 5-- $
Worksheets
Calendar Year 2004
Name ___________________________________________
Social Security # ___________________________________
